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Hallucinatory Experiences in Nonpsychotic Children
Hallucinatory Experiences in Nonpsychotic Children SOTIRIS KOTSOPOULOS, M.D ., JOEL KANIGSBERG, ED.D., ANDRE COTE, M.D ., AND CHRISTINA FIEDOROWICZ, PH.D. Abstract. Eleven children who experienced hallucinations were assessed and treated. The psychiatric diagnosis varied, but most children presented mood disturbance. mainly anxiety. Their level of adaptive functioning was substantiallyimpaired. The children wereeither socially inept or withdrawn. The hallucinationswereassociated mostly with bedtime and sleep phenomena. In the absence of other symptoms of psychosis no diagnosis of psychosis could be made. The hallucinationsceasedearly in the course of the treatment in nine children. J . Amer. Acad. Child Adol. Psychiat., 1987,26,3:375-380. Key Words: hallucinations, childhood anxiety disorders. cian who wonders about the nature of the hallucinations in a pat ient. The literature, however, does not provide sufficient information concerning the necessary and sufficient conditions that make some children hallucinate. Furthermore. although there is some information concerning outcome for these children, there is generally not enough known about this important issue (Lukianowicz, 1969; Simonds, 1975). The aim of the present study was to explore the phenomenology and the evolution of the hallucinatory experiences in nonpsychot ic children, to identify associated symptoms, and to determine the prognostic sign ificance of the hallucinations.
Hallucinatory experiences among child psychiatric patients are not common. Hallucinations in children may be part of the clinical picture of eithe'r an organic psychosyndrome (drug toxicity, metabolic disorder, infection) or a seizure disorder or schizophrenia (Lewis, 1982). However, some children present with hallucinations in the absence of any other evidence of either organic brain pathology or psychosis. Most often the hallucinations in these children are auditory. Estimates on their frequency, based on outpatient charts, vary from 0.4 % (Eisenberg, 1962) and 1.1 % (Garralda, 1982) to 5.7% (Burke et al., 1985). Because hallucinations ma y be a symptom of serious psychiatric pathology requiring specific management procedures their significance in the differential diagnosis is important. The clinician is particularly concerned about whether hallucinations in a child are incipient symptoms of schizophrenia. Early clinical studies suggested that hallucinations tended to occur in imaginative children who were chronically neglected and deprived, such as those who lived in isolation in the impoverished environment of city ghettos (Bender and Lipkowitz, 1940; Wilking and Paoli , 1966). Bender and Lipkowitz suggested that hallucinations in these children "occur as an expression of a severe discrepancy between the child's needs and drives and the reality offered him" p. 489 . Others emphasized traumatic experiences or severe and chronic stress as etiological factors (Levin, 1932) associated with anxiety and depression (Lukianowicz, 1969; Simonds, 1975). The psychodynamic function of the hallucinations has also been discussed by various investigators. Hallucinations have been interpreted as an expression of the functions of the id, superego, or ego (Rothstein, 1981). The literature on hallucinations in children has not been extensive. Rothstein (1981), in a literature review, reported only 20 studies published between 1931 and 1981. Some of the studies (Bender and Lipkowitz, 1940; Levin , 1932; Lukianowicz, 1969; Simonds. 1975) that provided sufficiently documented case histories are particularly useful to the c1ini-
Method Definition
Hallucinations were defined as "perceptions without an external stimulus" (DeVaul and Hall. 1980. p. 92). Dreams were not included. No distinction was made between hallucinations proper and pseudo-hallucinations, as suggested by Jaspers (1963), because this would have imposed an artificial d ichotomy on phenomena that in the present sample of patients were found to be overlapping. Jaspers considered hallucinations proper as those perceived to occur from outside and pseudo-hallucinations as those occurring in the inner space . Others have also considered this dichotomy superfluous (Fish. 1974) or as having little differential and prognostic significance (DeVaul and Hall, 1980). A similar distinction of hallucinations in children is probably also superfluous, according to Bender (1970). She found that children with schizophrenia may at first experience hallucinations as emerging from within themselves but that in the course of their development. they eventually project their experiences to the outside world and perce ive them as if they had emerged from outside sources. Furthermore, experiences occurring at bedtime were not excluded, having been considered as merely hypnagogic. Had they been excluded, a very important part of the experiences of the pat ient s reported ·in this study would have been missed (see below).
Subjects R eceived Sept . 26. 1985: revised May 6, 1986: accepted July 16, 1986 . Dr. Kotsopoulos is Associate Profe ssor ofPsychiatry at the University (if Ottawa and Director of Children 's Out- Patient Department of the Royal Otta wa Hospital. Drs. Konigsberg and Fiedorowicz are Assistant Clinical Professors (if Psychology at the University (if Otta wa. Dr. Cbti' is Professor ofPsychiatry at {he University ofOttawa. Reprint requests to Dr. Kotsopoulos. Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa. KIZ 7K4, Canada. 0890·8567/87/2603-0381 $02.00/0 © 1987 by the American
The subjects were 11 children reported to have hallucinations at the time of their referral to the Children's Outpatient Department of the Ro yal Ottawa Hospital. This is one of the largest child psychiatric services in Ottawa, Ontario, and the subjects were among approximately 1,000 referrals to this service . Their ages ranged from 7 to 12 years. There were eight boys and three girls. Five children were referred because of the hallucinations; the remaining six were referred primarily for other associated psychiatric problems.
Academy of Child and Adolescent Psychiatry. 375
376
KOTSOPOULOS ET AL.
T ABLE I. Assessment Data Case
Age (yr)
Sex
7
M
8
F
9
M
7 12 9 8 8 12 8 9 10
10
M
7
11
M
7
1 2
M M
3
M
4
F
5
M
6
F
DSM-lII Clinical Diagnosis
Level Adaptive Functioning
Adjustment disorder (anxiety) Adjustment disorder (depression) Adjustment disorder (anxiety) Adjustment disorder (depression) Anxiety disorder Adjustment disorder (anxiety-conduct) Schizoid disorder of childhood Anxiety disorder Adjustment disorder (anxiety) Reading disability Anxiety disorder ADD with hyperactivity Adjustment disorder (anxiety) Reading disability
4 4 5 4 6 4
Information was recorded concerning the sensory modality involved in the hallucinatory experience, the content of the hallucinations, and the awareness about the faulty or pathological nature of the hallucinations and on the psychological meaningfulness of the hallucinations (Egdell and Kolvin, 1972). Information was also recorded concerning the associated affect and the circumstances during which the hallucinations occurred. All children were investigated extensively. In addition to the psychiatric. psychological, and school assessment, three children had a neurological assessment, three had a neuropsychological assessment, nine had an EEG, and one had a CT scan. Finally, each case was discussed in conference by two child psychiatrists, one of whom (S. K.) was involved in the assessment and treatment of the children. and a DSM-III diagnosis was made on the axes of clinical syndromes and level of adaptive functioning. Regarding the family background, there was particular interest in possible history of schizophrenia and on whether or not other family members had hallucinations. Furthermore. information was recorded on the treatment and on the evolution of the hallucinatory experiences during the treatment period. Results
Psychiatric diagnosis" The psychiatric diagnosis and the level of adaptive functioning are shown in Table I. None of the II children was considered psychotic on the DSM-III criteria. Most of them received the diagnosis of adjustment disorder. Three received the diagnosis of anxiety disorder and one of schizoid disorder of childhood. A common feature among all children was disturbance of mood, mainly in the form of anxiety. Most children were substantially impaired at the time of the referral as their rating on the scale of adaptive functioning indicates; one child was suicidal (case 4). It was noted that five children presented sleep disturbance, two of them serious (cases 4 and 7) (see below). Another common characteristic among the children was a The case histories of all JJ patients are available upon request from Dr. Kotsopoulos.
5 5 5 4 4
social ineptness and withdrawal. Most of them had no friends, and the parents of seven children stressed that their child was a "loner." Furthermore, as an understanding of these children developed, it was also found that most of them were experiencing a breakdown in the affective support a child normally receives from parents or parent substitutes. The affective support was an important condition that had to be taken care of in the treatment. The assessment for possible biological deficits showed an abnormal EEG in two children (cases 6 and 7) and reading disability in another two (cases 9 and II). Extensive psychological assessments were performed on all children. which included intellectual and personality evaluations. One child was tested by another agency (case 4). All children were found to have average or higher intellectual abilities, with two exceptions. One child was functioning at the lower end of the low average range (case 2) and one was in the borderline range (case 6). No consistent personality test profile was found among the children. Two of them (cases 5 and 7) showed no abnormal findings but may have been trying to portray an overly positive view of themselves. There was evidence of anxiety or depression in four cases. Rorschach test data (Exner and Weiner, 1982) on some subjects indicated the presence of unmet needs and a tendency toward an ideational style of dealing with their environment. The family background was investigated extensively. Information on the birth parents of three children was not available. The father of one child was unknown (case 4) and two were adopted (cases 6 and 10). Psychiatric pathology was identified in the extended maternal (alcoholism, insomnia) and paternal (possible schizoid personality disorder) family of one child (case I). The mother of another child had major depressive disorder (case 7). The mother of a third child had epilepsy and was on phenytoin. She had visual hallucinations when she started to have seizures at age 14 (case II). In the past history a variety of circumstances were encountered that may have adversely affected the children. One child (case I) had had meningitis, probably infectious, at the age of 15 months, which left no traceable organic sequelae. The same child experienced family dysharmony and break-up as well as several family moves. Two children (cases 8 and 10) were adopted at the age of 6 months and 4 months, respec-
HALLUCINATlONS IN NON PSYCHOTIC CHILDREN
tively, and the father of the former was killed in an accident 2 years before the referral. The second adopted child did not appear to fit into the adoptive family. One child experienced long grief after the sudden death of the stepfather 2 years before the assessment. One girl (case 4) grew up in a chaotic family environment, had been sexually abused by a maternal brother, and was living in a group home at the time she was assessed. Two children (cases 3 and II) were under great pressure to perform well in school. The first was in a French immersion" program; the second had an undiagnosed reading disability.
Hallucinations
Sensorv modalitv. All children had auditory hallucinations and five 'among them also had visual hallucinations. The visual hallucinations had the form of visual imagery accompanied often by an appropriate auditory component (cases 6, 7, and 10) or the rudimentary form of images often observed in night terrors (cases 5 and II) (Table 2). The experiences, resembling night terrors, were not considered as such because the children had vivid recollections of them. Night terrors are usually followed by amnesia (Keith, 1975). Duration. The time of the onset of the hallucinatory experiences could not be determined reliably in most children. In the majority, duration appeared short, that is, a few weeks or months. Three children (cases 1,7, and 10) were known to have had the hallucinations for over I year. Source. Six children experienced the "voices" as emerging from within their own body, or the inner space, to use Jasper's terms. The remaining five felt that the voice emerged either from inside or outside their body. Only three children appeared sure that the hallucinations were nonreal in nature (cases I, 7, and 10); they all indicated that their experiences were products of their mind. The rest were uncertain about the nature of the experience or attributed it to alien sources (Table 2). Associated affect. The affect varied. Some children experienced intense fear or anxiety (cases I, 4, 5, 10, and II); one experienced anger (case 2); one felt comfort (case 3). The remaining possibly experienced some distress. Content. The "voices" urged most children, in the imperative form, to take some action, mostly aggressive, which was directed against someone the child knew, either another child or an adult; in two cases the adult was the teacher. The "voices" in two children had a threatening and destructive content and one child was directed to commit suicide. Finally, one child found in the "voice" a friendly adult who, like a guardian angel, was trying to keep the child clear of trouble in the day ahead. The auditory experience in two children were sounds; one (case I 1) heard the "big steps" of an approaching robot or the "roar of a grizzly bear"; the other (case 10) heard noises and voices. The "voices" in all children were well-formed statements from the linguistic point of view and made sense, and in some of them the statement fitted well with the child's conflicts and tensions. For example, the young girl (case 4) who was being advised to commit suicide was in fact feeling very guilty about " This is a special school program for Anglophone children. The language of instruction is 100% French in grades J and 2. In the following grades English is also introduced in the program.
377
having been sexually abused by an uncle. The young boy (case 7) who was being advised by the "voice" to attack and ridicule the teacher was experiencing intense strain in school and was failing academically. Most children resisted the imperative advice of the "voice," but a few at times gave in. For example, the 12-year-old boy (case 2) had temper outbursts in class and banged his desk while the "voice" advised him to "get back at the teacher." The 12-year-old girl (case 6) ran away on the advice of the "voice." The IO-year-old boy (case 9) knocked another child ofThis bicycle on the command of the "voice." The content of the visual hallucinations was either frightening (cases 5, 10, and II), upsetting (case 7), or reassuring and instructive (case 6). Associated circumstances. The period of time during which most children were likely to hallucinate was bedtime (Table 2). In fact, five children had the hallucinatory experience only when they were alone in their rooms at bedtime (cases 3, 4, 5, 6, and 8). Four more children experienced the hallucinations predominantly at bedtime (cases I, 7, 10, and II). The experience might occur before going to sleep, upon awaking during the night, or in the morning. Two children were also awakened by the "voice" (cases 4 and 6), which continued to "talk" while they were awake. Another child (case 5), in addition to a threatening voice he experienced while awake, was also awakened in the midst of a nightmare by a "man without a head" and continued to have the same experience in wakefulness as combined auditory and visual hallucinations. This child had a vivid .recollection of his night experiences and was overwhelmed with fear that he would be killed in his house by the monster. The two children (cases 2 and 9) who did not present an obvious association between their hallucinatory experiences and sleep related phenomena complained nevertheless of recurring nightmares. It may, therefore, be suggested that hallucinatory experiences in children are frequently related to bedtime and sleep. Why these experiences were not considered hypnagogic or hypnopompic will be dealt with subsequently. Treatment. As our understanding of the hallucinatory experiences increased, in treatment their presence was considered an indicator of severity of stress, anxiety, and failing coping mechanisms in the child rather than a symptom of specific psychopathology. The objectives of the treatment were basically determined by the underlying problems the child was experiencing. With two exceptions (cases 2 and II) the treatment involved the child, the family, and the school. Some children required short-term supportive psychotherapy in association with parental and school counseling. Two (cases 4 and 5) required long-term individual psychotherapy, and one child (case 7) needed placement in a special school and day-care program. Psychotropic drugs were also used in four children for a short period of time to control the sleep disturbance. The two children who were not involved in treatment (cases 2 and 11) were nevertheless supported indirectly in that the parents and schools were advised on the nature of their disorder. Outcome. The hallucinations began to fade in six children soon after treatment was started and they ceased within a period of time ranging from I to 5 weeks. The hallucinations ceased in most children even before the underlying problems had been resolved. This is an observation that will be discussed below. One child (case 5) continued to present mood swings,
378
KOTSOPOULOS ET AL. TABLE
Case
Modality
2.
Phenomenology ofHallucinations
Source
Content
Associated Circumstances
---------~-
Auditory
"A bunch of kids in the head"; one of them was a friend
2
Auditory
"Devil" or "bad woman or bad man" in the head
3
Auditory
A friendly man talks from the child's closet; experience elicited often at will with "a magic" move of hands
4
Auditory
A female or male voice "in between" with echo features, inside or outside the head
5
Auditory Visual
6
Auditory Visual
Voice of a monster, "a man without head," whom child may see upon waking up in the midst of a nightmare Own voice inside the head; uncertain about visual experience
7
Auditory Visual
Voice of brother and mother inside the head; child believes his experiences are happening in his "mind"
8
Auditory
9
Auditory
Voice of a "white woman" who was either an "angel or a robot" and the deep voice of a "red man" Voice of a man, sounds like lather's but it is not, outside or inside the body or head
10
Visual Auditory
Child says that what he sees and hears "is not true"; it happens "in the head"
II
Visual Auditory Kinesthetic
Child perceives his experiences as being real
Frightening: Murderer hiding or monster lurking in the house Urging: Disobedience and aggressiveness (child usually does not follow advice) Urging: Aggressiveness and retaliation (child may resist or follow advice) Alerting: About possible trouble in the day ahead; child "changes attitude" accordingly Urging: "Go to the knives," "kill yourself' (child reo sists but afraid of giving in)
Frightening: "I will kill you"
Urging: Disobedience to parents, and "run" (child ran a few times) Viewing: Jesus going about and "talking" Urging: Brother tells him to attack the teacher "throw a pie, put a needle, put a whoopee cushion." Mother tells him to eat his lunch and do his work in school. Viewing: Family members in minuscule form fighting-arguing Urging: To do "good thing" (female voice), to do "bad things" (male voice) Urging: Disobedience and aggressiveness (child may resist or follow advice)
Frightening: A spook bending over his window; a skeleton tapping him on the shoulder Hearing: Noises Frightening: "A big arm" breaking through the wall of the house. "Lights," which are "asteroids coming after him" Hearing: Sounds of a robot or a grizzly bear approaching Feeling: Tingling sensation on nose where a "bubble has grown"
"Voices" may occur any time; frightening at home in the evening; nightmares of terrifying content; child blames "voices" for "giving bad dreams"
"Voice talks" while in class or at home; nightmares and sleep talking and screaming "Voice" elicited while child alone in room, in bed, either before going to sleep or upon waking up in the morning "Voice" talks while child in bed, evening or morning, and roommate asleep; rocks to get to sleep; "voice" may awaken child (no visible content) and "continue to talk" Child hears the voice when alone in his room; experience may also start as nightmare and continue while child awake "Voice talks" and visual experience occurs while child alone in her room mostly at night; "voice" may also start as a dream and continue while child awake Combined auditory-visual experience only while child alone in bed at night; cannot get to sleep and wakes up several times; rocks and mumbles
"Voices" may talk only when child is in bed in the evening or morning upon waking up "Voice" may talk any time; child dreams of waterskiing followed by sharks ("voice" first heard while water-skiing in the Carribean) Child "sees" spook and a skeleton in his room while lights on; has dreams similar in content: gets noises while in class when he blocks ear with palm The visual and auditory experiences are frightening in the night upon awakening; the lights, "brown, gray," may be experienced in the daytime and unfold over a longer period of time.
HALLUCINATIONS IN NON PSYCHOTIC CHILDREN
and temper outbursts 18 months after he was first seen. although his hallucinatory experiences stopped. In three more children the hallucinations also faded during or shortly after the assessment and counseling period (cases 2 and II) or during treatment (case 10). In one of them (case 2) the hallucinations probably ceased altogether during the follow-up period. but in the remaining two. visual experiences persisted in the form of "ghosts" seen infrequently (case 10) and "colors. shapes. shades (ghostlike)" (case II). The persisting visual experiences of these two children were no longer associated with substantial fear or anxiety. Two children did not respond to the treatment. One (case I) was a 7-year-old boy who had had hallucinations for Ph years. He did not show reduction in the frequency of hallucinations despite improvement of functioning in school and home. This child received individual psychotherapy and family therapy. Two years after the termination of treatment the child continued to have the same experiences. A second child (case 7). who was diagnosed as having schizoid disorder of childhood. continued to experience hallucinations and sleep disturbance. was socially withdrawn. and was failing in school at the conclusion of the outpatient treatment 5 months after the initial assessment. Eight months later. in a special day program. he was showing some improvement. Discussion Before returning to the questions this study undertook to answer. it should be explained why hallucinations that occurred at bedtime were not considered hypnagogic and were therefore of dubious clinical value . First . although some experiences (cases 4. 5. 6. 7. and II) might be considered hypnagogic or hypnopompic because of their temporal characteristics (Mavromatis and Richardson. 1984). overall there was no clear demarcation line in form and content between daytime hallucinatory experiences and those occurring at bedtime (cases I and II) and between the latter and those associated with sleep disturbance (cases 4. 5. 6. and II). Furthermore. the hallucinatory experiences of two children (cases 1 and 10) were very similar in content to nightmares. It appeared. therefore. that there was a continuum of phen omena ranging from hallucinations occurring in the daytime to those occurring at bedtime and to dreams. There were also children who hallucinated both in the daytime and at bedtime (cases I. 7. 10. and I I). The absence of clear-cut differences between the various forms of hallucinatory experiences within and between patients is in accordance with the theory which postulates that. in fact. these experiences are not sharply distinguishable and can evolve from one to another and that they are probably underlined by the same internal mechanisms (Savage. 1975). According to this theory. sensations. perceptions. hallucinations. dreams. fantasies. and thoughts are composed of the same substance and differ not in kind but in degree (Savage. 1975). The absence of fundamental qual itative differences. however. between hallucinations. dreams. and fantasies does not invalidate the different clinical and prognostic significance of these phenomena that has been established on clinical grounds. Second. the impression of the clinicians was that most hallucinatory experiences in the present sample of patients
379
occurred not at the moment of falling asleep. They seemed to occur when the child was alone in his or her bedroom and everything was quiet. The propensity of most children to hallucinate at bedtime is in keeping with theories suggesting that the hallucinatory experience is more likely to emerge when the external flow of stimuli. primarily auditory. drops while the level of arousal remains high (West. 1975). High arousal level associated with emotional disturbance was probably present in most patients. They were all assessed as showing emotional disturbance mainly in the form ofanxiety. Lukianowicz (1969) and Simonds (1975) made similar observations on their patients (14 and 10. respectively). Third. the experiences of the patients were called hallucinations. not hypnagogic hallucinations. by those who referred the children to the Service and who were obviously unaware that these experiences occurred often at bedtime. By consensus. therefore. the phenomena studied were called hallucinations. The hallucinatory experiences of the patients reported here. in the absence of other symptoms of psychosis. were not sufficient to diagnose psychosis. Furthermore. the hallucinations were coherent. made sense. and in some children were congruent with their life experiences and circumstances. Hallucinations in schizophrenic children are usually associated with a host of other symptoms. are bizarre. and they often make no sense (Bender. 1970: Eggers. 1978: Portell. 1970). The hallucinations of most patients were reversed early in the course of treatment. A similar outcome in his patients was reported by Lukianowicz (1969) . The early reversal of the hallucinatory experiences. or else the favorable outcome. was probably due to two factors . First. it was the unconditional alliance and support offered to most children by therapists. Second. it was the alleviation of stress that was associated with counseling and with substantial changes in the life circumstances of some children. e.g.. placement in appropriate school program (cases 3. 8. and II). The evidence therefore suggests that the short-term prognosis regarding the hallucinatory experiences is generally good provided that the associated emotional disturbance and stress factors have been understood and dealt with effectively. Other underlying conditions (e.g.. attention deficit disorder. learning disability) will eventually continue their natural history course. The intervention was ineffective in one child (case I). At least two conditions stood out as being specific to him . First. he started to hallucinate at age 5 1h years and for 1112 years he received no professional help . By the time he was assessed and treated. therefore. this child was a chronic case. Secondly. this was an unusually reflective child for his age who would not become involved in play. Instead. he would converse as a much older child . It was not possible to determine whether his family psychiatric history and meningitis in infancy were important factors . A second child (case 7). with schizoid disorder. was showing some improvement but this appeared to be precarious. The hallucinatory experiences in this child were obviously associated with serious psychiatric pathology compatible in many respects with a borderline syndrome as described by Bemporad et al. (1982) . Whether hallucinations in children may be considered precursors of an imaginative person. such as an artist or a writer. as it has been postulated by Wilson and Barber (1983).
380
KOTSOPOULOS ET AL.
is difficult to tell. Only two of the patients (cases I and 7) appeared to have rich imaginary lives. They were, in fact, the two with poor outcomes. Regarding the psychodynamics of the hallucinatory experience, it may be speculated that all patients under conditions of heightened stress who were feeling either isolated or unsupported by sources of affective support, such as parents, experienced disassociation in the functions of the self. The disassociated part was projected to an alien source and became the hallucinatory experience. After treatment commenced the child felt supported and the stress eased. Consequently, the child started to deal with his or her problems without feeling overwhelmed or helpless; then, the hallucinations ceased. As the number of the subjects of the present study was small. firm conclusions may not be drawn about the issues this study attempted to address. The results of the study, however, may be useful in developing hypotheses on the psychopathology that underlines hallucinatory experiences in children. One hypothesis may be that intense emotional disturbance and high arousal level associated with chronic stress, and social ineptness, withdrawal, and disruption in the affective support the child normally receives from parental figures, are necessary but probably not sufficient factors for the emergence of the hallucinatory experience. What the additional necessary and sufficient factors are, perhaps in the form of some inner vulnerability, has yet to be determined.
References Bernporad, J. R.. Smith, H. F., Hanson, G. & Ciccheti, D. (1982), Borderline syndromes in childhood: criteria for diagnosis. Amer. J. Psychiat., 139:596-602. Bender, L. (1970), The maturation process and hallucinations in children. In: Origin and Mechanisms (if Hallucinations, cd. W. Kemp. New York: Plenum, pp. 95-101. - - & Lipkowitz, H. H. (1940), Hallucinations in children. Amer. 1. Orthopsvchiat., 10:471-490. Burke, P.. Delbeccaro, H., McCauley, E. & Clark, C. (1985), Hallucinations in children. This Journal, 24:71-75. DeVaul, R. A. & Hall, R. C. W. (1980), Hallucinations. In: Psychiatric Presentations of Medical Illness, ed. R. C. W. Hall. Spectrum Publications, pp. 91-103.
Egdell, H. G. & Kolvin, I. (1972), Childhood hallucinations. J. Child Psychol. Psychiat., 13:279-287. Eggers, C. (1978), Course and prognosis of childhood schizophrenia. 1. Aut. Childh. Schi:o., 8:21-36. Eisenberg, L. (1962), Hallucinations in children. In: Hallucinations, cd. L. J. West. New York: Grune & Stratton, pp. 198-207. Exner, J. E. Jr. & Weiner, I. B. (1982), The Rorschach: A Comprehensive System, Vo!' 3. Assessment of Children and Adolescents. New York: Wiley. . Fish, F. (1974), Fish's Clinical Psychopathology, ed. M. Hamilton. Bristol: John Wright & Sons. Garralda, M. E. (1982), Hallucinations in psychiatrically disordered children: preliminary communication. J. Royal Soc. Med., 75: 181184. Jaspers, K. (1963), General Psychopathology. trans. J. Hoenig & M. W. Hamilton. Chicago: University of Chicago Press. Keith, P. R. (1975), Night Terrors: a review of psychology, neurophysiology and therapy. This Journal, 14:477-489. Levin, M. (1932), Auditory hallucinations in non-psychotic children. Amer. J. Psychiat., 88:1119-1152. Lewis, M. (1982). Clinical Aspects (If Child Development. Philadelphia: Lea & Febiger. Lukianowicz, N. (1969), Hallucinations in non-psychotic children. Psvchiat. Clin., 2:321-337. Mavromatis, A. & Richardson, J. T. E. (1984), Hypnagogic imagery. In: International Review of Mental Imagery. Vol. I, ed. A. A. Sheikh. New York: Human Sciences Press, pp. 159-189. Portell, J. (1970), Hallucinations in pre-adolescent schizophrenic children. In: Origin and Mechanisms (if Hallucinations, cd. W. Keup. New York: Plenum, pp. 405-411. Rothstein, A. (1981), Hallucinatory phenomena in childhood: a critique of the literature. This Journal, 20:623-635. Savage, C. W. (1975), The continuity of perceptual and cognitive experiences. In: Hallucinations, cds. R. K Siegel & L. J. West. New York: Wiley, pp. 257-286. Simonds, J. F. (1975), Hallucinations in non-psychotic children and adolescents. 1. Youth Adolesc., 4: 171-182. West, L. J. (1975), A clinical and theoretical overview of hallucinatory phenomena. In: Hallucinations, eds. R. K. Siegel & L. J West. New York: Wiley, pp. 287-311. Wilking, V. N. & Paoli, C. (1966), The hallucinatory experience. This Journal,5:431-440. Wilson, S. C. & Barber, T. X. (1983), The fantasy-prone personality: implications for understanding imagery, hypnosis, and parapsychological phenomena. In: Imagery, Current Theory, Research and Application, ed. A. A. Sheikh. New York: Wiley pp. 340-387.
Hallucinatory experiences among child psychiatric patients are not common. Hallucinations in children may be part of the clinical picture of eithe'r an organic psychosyndrome (drug toxicity, metabolic disorder, infection) or a seizure disorder or schizophrenia (Lewis, 1982). However, some children present with hallucinations in the absence of any other evidence of either organic brain pathology or psychosis. Most often the hallucinations in these children are auditory. Estimates on their frequency, based on outpatient charts, vary from 0.4 % (Eisenberg, 1962) and 1.1 % (Garralda, 1982) to 5.7% (Burke et al., 1985). Because hallucinations ma y be a symptom of serious psychiatric pathology requiring specific management procedures their significance in the differential diagnosis is important. The clinician is particularly concerned about whether hallucinations in a child are incipient symptoms of schizophrenia. Early clinical studies suggested that hallucinations tended to occur in imaginative children who were chronically neglected and deprived, such as those who lived in isolation in the impoverished environment of city ghettos (Bender and Lipkowitz, 1940; Wilking and Paoli , 1966). Bender and Lipkowitz suggested that hallucinations in these children "occur as an expression of a severe discrepancy between the child's needs and drives and the reality offered him" p. 489 . Others emphasized traumatic experiences or severe and chronic stress as etiological factors (Levin, 1932) associated with anxiety and depression (Lukianowicz, 1969; Simonds, 1975). The psychodynamic function of the hallucinations has also been discussed by various investigators. Hallucinations have been interpreted as an expression of the functions of the id, superego, or ego (Rothstein, 1981). The literature on hallucinations in children has not been extensive. Rothstein (1981), in a literature review, reported only 20 studies published between 1931 and 1981. Some of the studies (Bender and Lipkowitz, 1940; Levin , 1932; Lukianowicz, 1969; Simonds. 1975) that provided sufficiently documented case histories are particularly useful to the c1ini-
Method Definition
Hallucinations were defined as "perceptions without an external stimulus" (DeVaul and Hall. 1980. p. 92). Dreams were not included. No distinction was made between hallucinations proper and pseudo-hallucinations, as suggested by Jaspers (1963), because this would have imposed an artificial d ichotomy on phenomena that in the present sample of patients were found to be overlapping. Jaspers considered hallucinations proper as those perceived to occur from outside and pseudo-hallucinations as those occurring in the inner space . Others have also considered this dichotomy superfluous (Fish. 1974) or as having little differential and prognostic significance (DeVaul and Hall, 1980). A similar distinction of hallucinations in children is probably also superfluous, according to Bender (1970). She found that children with schizophrenia may at first experience hallucinations as emerging from within themselves but that in the course of their development. they eventually project their experiences to the outside world and perce ive them as if they had emerged from outside sources. Furthermore, experiences occurring at bedtime were not excluded, having been considered as merely hypnagogic. Had they been excluded, a very important part of the experiences of the pat ient s reported ·in this study would have been missed (see below).
Subjects R eceived Sept . 26. 1985: revised May 6, 1986: accepted July 16, 1986 . Dr. Kotsopoulos is Associate Profe ssor ofPsychiatry at the University (if Ottawa and Director of Children 's Out- Patient Department of the Royal Otta wa Hospital. Drs. Konigsberg and Fiedorowicz are Assistant Clinical Professors (if Psychology at the University (if Otta wa. Dr. Cbti' is Professor ofPsychiatry at {he University ofOttawa. Reprint requests to Dr. Kotsopoulos. Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa. KIZ 7K4, Canada. 0890·8567/87/2603-0381 $02.00/0 © 1987 by the American
The subjects were 11 children reported to have hallucinations at the time of their referral to the Children's Outpatient Department of the Ro yal Ottawa Hospital. This is one of the largest child psychiatric services in Ottawa, Ontario, and the subjects were among approximately 1,000 referrals to this service . Their ages ranged from 7 to 12 years. There were eight boys and three girls. Five children were referred because of the hallucinations; the remaining six were referred primarily for other associated psychiatric problems.
Academy of Child and Adolescent Psychiatry. 375
376
KOTSOPOULOS ET AL.
T ABLE I. Assessment Data Case
Age (yr)
Sex
7
M
8
F
9
M
7 12 9 8 8 12 8 9 10
10
M
7
11
M
7
1 2
M M
3
M
4
F
5
M
6
F
DSM-lII Clinical Diagnosis
Level Adaptive Functioning
Adjustment disorder (anxiety) Adjustment disorder (depression) Adjustment disorder (anxiety) Adjustment disorder (depression) Anxiety disorder Adjustment disorder (anxiety-conduct) Schizoid disorder of childhood Anxiety disorder Adjustment disorder (anxiety) Reading disability Anxiety disorder ADD with hyperactivity Adjustment disorder (anxiety) Reading disability
4 4 5 4 6 4
Information was recorded concerning the sensory modality involved in the hallucinatory experience, the content of the hallucinations, and the awareness about the faulty or pathological nature of the hallucinations and on the psychological meaningfulness of the hallucinations (Egdell and Kolvin, 1972). Information was also recorded concerning the associated affect and the circumstances during which the hallucinations occurred. All children were investigated extensively. In addition to the psychiatric. psychological, and school assessment, three children had a neurological assessment, three had a neuropsychological assessment, nine had an EEG, and one had a CT scan. Finally, each case was discussed in conference by two child psychiatrists, one of whom (S. K.) was involved in the assessment and treatment of the children. and a DSM-III diagnosis was made on the axes of clinical syndromes and level of adaptive functioning. Regarding the family background, there was particular interest in possible history of schizophrenia and on whether or not other family members had hallucinations. Furthermore. information was recorded on the treatment and on the evolution of the hallucinatory experiences during the treatment period. Results
Psychiatric diagnosis" The psychiatric diagnosis and the level of adaptive functioning are shown in Table I. None of the II children was considered psychotic on the DSM-III criteria. Most of them received the diagnosis of adjustment disorder. Three received the diagnosis of anxiety disorder and one of schizoid disorder of childhood. A common feature among all children was disturbance of mood, mainly in the form of anxiety. Most children were substantially impaired at the time of the referral as their rating on the scale of adaptive functioning indicates; one child was suicidal (case 4). It was noted that five children presented sleep disturbance, two of them serious (cases 4 and 7) (see below). Another common characteristic among the children was a The case histories of all JJ patients are available upon request from Dr. Kotsopoulos.
5 5 5 4 4
social ineptness and withdrawal. Most of them had no friends, and the parents of seven children stressed that their child was a "loner." Furthermore, as an understanding of these children developed, it was also found that most of them were experiencing a breakdown in the affective support a child normally receives from parents or parent substitutes. The affective support was an important condition that had to be taken care of in the treatment. The assessment for possible biological deficits showed an abnormal EEG in two children (cases 6 and 7) and reading disability in another two (cases 9 and II). Extensive psychological assessments were performed on all children. which included intellectual and personality evaluations. One child was tested by another agency (case 4). All children were found to have average or higher intellectual abilities, with two exceptions. One child was functioning at the lower end of the low average range (case 2) and one was in the borderline range (case 6). No consistent personality test profile was found among the children. Two of them (cases 5 and 7) showed no abnormal findings but may have been trying to portray an overly positive view of themselves. There was evidence of anxiety or depression in four cases. Rorschach test data (Exner and Weiner, 1982) on some subjects indicated the presence of unmet needs and a tendency toward an ideational style of dealing with their environment. The family background was investigated extensively. Information on the birth parents of three children was not available. The father of one child was unknown (case 4) and two were adopted (cases 6 and 10). Psychiatric pathology was identified in the extended maternal (alcoholism, insomnia) and paternal (possible schizoid personality disorder) family of one child (case I). The mother of another child had major depressive disorder (case 7). The mother of a third child had epilepsy and was on phenytoin. She had visual hallucinations when she started to have seizures at age 14 (case II). In the past history a variety of circumstances were encountered that may have adversely affected the children. One child (case I) had had meningitis, probably infectious, at the age of 15 months, which left no traceable organic sequelae. The same child experienced family dysharmony and break-up as well as several family moves. Two children (cases 8 and 10) were adopted at the age of 6 months and 4 months, respec-
HALLUCINATlONS IN NON PSYCHOTIC CHILDREN
tively, and the father of the former was killed in an accident 2 years before the referral. The second adopted child did not appear to fit into the adoptive family. One child experienced long grief after the sudden death of the stepfather 2 years before the assessment. One girl (case 4) grew up in a chaotic family environment, had been sexually abused by a maternal brother, and was living in a group home at the time she was assessed. Two children (cases 3 and II) were under great pressure to perform well in school. The first was in a French immersion" program; the second had an undiagnosed reading disability.
Hallucinations
Sensorv modalitv. All children had auditory hallucinations and five 'among them also had visual hallucinations. The visual hallucinations had the form of visual imagery accompanied often by an appropriate auditory component (cases 6, 7, and 10) or the rudimentary form of images often observed in night terrors (cases 5 and II) (Table 2). The experiences, resembling night terrors, were not considered as such because the children had vivid recollections of them. Night terrors are usually followed by amnesia (Keith, 1975). Duration. The time of the onset of the hallucinatory experiences could not be determined reliably in most children. In the majority, duration appeared short, that is, a few weeks or months. Three children (cases 1,7, and 10) were known to have had the hallucinations for over I year. Source. Six children experienced the "voices" as emerging from within their own body, or the inner space, to use Jasper's terms. The remaining five felt that the voice emerged either from inside or outside their body. Only three children appeared sure that the hallucinations were nonreal in nature (cases I, 7, and 10); they all indicated that their experiences were products of their mind. The rest were uncertain about the nature of the experience or attributed it to alien sources (Table 2). Associated affect. The affect varied. Some children experienced intense fear or anxiety (cases I, 4, 5, 10, and II); one experienced anger (case 2); one felt comfort (case 3). The remaining possibly experienced some distress. Content. The "voices" urged most children, in the imperative form, to take some action, mostly aggressive, which was directed against someone the child knew, either another child or an adult; in two cases the adult was the teacher. The "voices" in two children had a threatening and destructive content and one child was directed to commit suicide. Finally, one child found in the "voice" a friendly adult who, like a guardian angel, was trying to keep the child clear of trouble in the day ahead. The auditory experience in two children were sounds; one (case I 1) heard the "big steps" of an approaching robot or the "roar of a grizzly bear"; the other (case 10) heard noises and voices. The "voices" in all children were well-formed statements from the linguistic point of view and made sense, and in some of them the statement fitted well with the child's conflicts and tensions. For example, the young girl (case 4) who was being advised to commit suicide was in fact feeling very guilty about " This is a special school program for Anglophone children. The language of instruction is 100% French in grades J and 2. In the following grades English is also introduced in the program.
377
having been sexually abused by an uncle. The young boy (case 7) who was being advised by the "voice" to attack and ridicule the teacher was experiencing intense strain in school and was failing academically. Most children resisted the imperative advice of the "voice," but a few at times gave in. For example, the 12-year-old boy (case 2) had temper outbursts in class and banged his desk while the "voice" advised him to "get back at the teacher." The 12-year-old girl (case 6) ran away on the advice of the "voice." The IO-year-old boy (case 9) knocked another child ofThis bicycle on the command of the "voice." The content of the visual hallucinations was either frightening (cases 5, 10, and II), upsetting (case 7), or reassuring and instructive (case 6). Associated circumstances. The period of time during which most children were likely to hallucinate was bedtime (Table 2). In fact, five children had the hallucinatory experience only when they were alone in their rooms at bedtime (cases 3, 4, 5, 6, and 8). Four more children experienced the hallucinations predominantly at bedtime (cases I, 7, 10, and II). The experience might occur before going to sleep, upon awaking during the night, or in the morning. Two children were also awakened by the "voice" (cases 4 and 6), which continued to "talk" while they were awake. Another child (case 5), in addition to a threatening voice he experienced while awake, was also awakened in the midst of a nightmare by a "man without a head" and continued to have the same experience in wakefulness as combined auditory and visual hallucinations. This child had a vivid .recollection of his night experiences and was overwhelmed with fear that he would be killed in his house by the monster. The two children (cases 2 and 9) who did not present an obvious association between their hallucinatory experiences and sleep related phenomena complained nevertheless of recurring nightmares. It may, therefore, be suggested that hallucinatory experiences in children are frequently related to bedtime and sleep. Why these experiences were not considered hypnagogic or hypnopompic will be dealt with subsequently. Treatment. As our understanding of the hallucinatory experiences increased, in treatment their presence was considered an indicator of severity of stress, anxiety, and failing coping mechanisms in the child rather than a symptom of specific psychopathology. The objectives of the treatment were basically determined by the underlying problems the child was experiencing. With two exceptions (cases 2 and II) the treatment involved the child, the family, and the school. Some children required short-term supportive psychotherapy in association with parental and school counseling. Two (cases 4 and 5) required long-term individual psychotherapy, and one child (case 7) needed placement in a special school and day-care program. Psychotropic drugs were also used in four children for a short period of time to control the sleep disturbance. The two children who were not involved in treatment (cases 2 and 11) were nevertheless supported indirectly in that the parents and schools were advised on the nature of their disorder. Outcome. The hallucinations began to fade in six children soon after treatment was started and they ceased within a period of time ranging from I to 5 weeks. The hallucinations ceased in most children even before the underlying problems had been resolved. This is an observation that will be discussed below. One child (case 5) continued to present mood swings,
378
KOTSOPOULOS ET AL. TABLE
Case
Modality
2.
Phenomenology ofHallucinations
Source
Content
Associated Circumstances
---------~-
Auditory
"A bunch of kids in the head"; one of them was a friend
2
Auditory
"Devil" or "bad woman or bad man" in the head
3
Auditory
A friendly man talks from the child's closet; experience elicited often at will with "a magic" move of hands
4
Auditory
A female or male voice "in between" with echo features, inside or outside the head
5
Auditory Visual
6
Auditory Visual
Voice of a monster, "a man without head," whom child may see upon waking up in the midst of a nightmare Own voice inside the head; uncertain about visual experience
7
Auditory Visual
Voice of brother and mother inside the head; child believes his experiences are happening in his "mind"
8
Auditory
9
Auditory
Voice of a "white woman" who was either an "angel or a robot" and the deep voice of a "red man" Voice of a man, sounds like lather's but it is not, outside or inside the body or head
10
Visual Auditory
Child says that what he sees and hears "is not true"; it happens "in the head"
II
Visual Auditory Kinesthetic
Child perceives his experiences as being real
Frightening: Murderer hiding or monster lurking in the house Urging: Disobedience and aggressiveness (child usually does not follow advice) Urging: Aggressiveness and retaliation (child may resist or follow advice) Alerting: About possible trouble in the day ahead; child "changes attitude" accordingly Urging: "Go to the knives," "kill yourself' (child reo sists but afraid of giving in)
Frightening: "I will kill you"
Urging: Disobedience to parents, and "run" (child ran a few times) Viewing: Jesus going about and "talking" Urging: Brother tells him to attack the teacher "throw a pie, put a needle, put a whoopee cushion." Mother tells him to eat his lunch and do his work in school. Viewing: Family members in minuscule form fighting-arguing Urging: To do "good thing" (female voice), to do "bad things" (male voice) Urging: Disobedience and aggressiveness (child may resist or follow advice)
Frightening: A spook bending over his window; a skeleton tapping him on the shoulder Hearing: Noises Frightening: "A big arm" breaking through the wall of the house. "Lights," which are "asteroids coming after him" Hearing: Sounds of a robot or a grizzly bear approaching Feeling: Tingling sensation on nose where a "bubble has grown"
"Voices" may occur any time; frightening at home in the evening; nightmares of terrifying content; child blames "voices" for "giving bad dreams"
"Voice talks" while in class or at home; nightmares and sleep talking and screaming "Voice" elicited while child alone in room, in bed, either before going to sleep or upon waking up in the morning "Voice" talks while child in bed, evening or morning, and roommate asleep; rocks to get to sleep; "voice" may awaken child (no visible content) and "continue to talk" Child hears the voice when alone in his room; experience may also start as nightmare and continue while child awake "Voice talks" and visual experience occurs while child alone in her room mostly at night; "voice" may also start as a dream and continue while child awake Combined auditory-visual experience only while child alone in bed at night; cannot get to sleep and wakes up several times; rocks and mumbles
"Voices" may talk only when child is in bed in the evening or morning upon waking up "Voice" may talk any time; child dreams of waterskiing followed by sharks ("voice" first heard while water-skiing in the Carribean) Child "sees" spook and a skeleton in his room while lights on; has dreams similar in content: gets noises while in class when he blocks ear with palm The visual and auditory experiences are frightening in the night upon awakening; the lights, "brown, gray," may be experienced in the daytime and unfold over a longer period of time.
HALLUCINATIONS IN NON PSYCHOTIC CHILDREN
and temper outbursts 18 months after he was first seen. although his hallucinatory experiences stopped. In three more children the hallucinations also faded during or shortly after the assessment and counseling period (cases 2 and II) or during treatment (case 10). In one of them (case 2) the hallucinations probably ceased altogether during the follow-up period. but in the remaining two. visual experiences persisted in the form of "ghosts" seen infrequently (case 10) and "colors. shapes. shades (ghostlike)" (case II). The persisting visual experiences of these two children were no longer associated with substantial fear or anxiety. Two children did not respond to the treatment. One (case I) was a 7-year-old boy who had had hallucinations for Ph years. He did not show reduction in the frequency of hallucinations despite improvement of functioning in school and home. This child received individual psychotherapy and family therapy. Two years after the termination of treatment the child continued to have the same experiences. A second child (case 7). who was diagnosed as having schizoid disorder of childhood. continued to experience hallucinations and sleep disturbance. was socially withdrawn. and was failing in school at the conclusion of the outpatient treatment 5 months after the initial assessment. Eight months later. in a special day program. he was showing some improvement. Discussion Before returning to the questions this study undertook to answer. it should be explained why hallucinations that occurred at bedtime were not considered hypnagogic and were therefore of dubious clinical value . First . although some experiences (cases 4. 5. 6. 7. and II) might be considered hypnagogic or hypnopompic because of their temporal characteristics (Mavromatis and Richardson. 1984). overall there was no clear demarcation line in form and content between daytime hallucinatory experiences and those occurring at bedtime (cases I and II) and between the latter and those associated with sleep disturbance (cases 4. 5. 6. and II). Furthermore. the hallucinatory experiences of two children (cases 1 and 10) were very similar in content to nightmares. It appeared. therefore. that there was a continuum of phen omena ranging from hallucinations occurring in the daytime to those occurring at bedtime and to dreams. There were also children who hallucinated both in the daytime and at bedtime (cases I. 7. 10. and I I). The absence of clear-cut differences between the various forms of hallucinatory experiences within and between patients is in accordance with the theory which postulates that. in fact. these experiences are not sharply distinguishable and can evolve from one to another and that they are probably underlined by the same internal mechanisms (Savage. 1975). According to this theory. sensations. perceptions. hallucinations. dreams. fantasies. and thoughts are composed of the same substance and differ not in kind but in degree (Savage. 1975). The absence of fundamental qual itative differences. however. between hallucinations. dreams. and fantasies does not invalidate the different clinical and prognostic significance of these phenomena that has been established on clinical grounds. Second. the impression of the clinicians was that most hallucinatory experiences in the present sample of patients
379
occurred not at the moment of falling asleep. They seemed to occur when the child was alone in his or her bedroom and everything was quiet. The propensity of most children to hallucinate at bedtime is in keeping with theories suggesting that the hallucinatory experience is more likely to emerge when the external flow of stimuli. primarily auditory. drops while the level of arousal remains high (West. 1975). High arousal level associated with emotional disturbance was probably present in most patients. They were all assessed as showing emotional disturbance mainly in the form ofanxiety. Lukianowicz (1969) and Simonds (1975) made similar observations on their patients (14 and 10. respectively). Third. the experiences of the patients were called hallucinations. not hypnagogic hallucinations. by those who referred the children to the Service and who were obviously unaware that these experiences occurred often at bedtime. By consensus. therefore. the phenomena studied were called hallucinations. The hallucinatory experiences of the patients reported here. in the absence of other symptoms of psychosis. were not sufficient to diagnose psychosis. Furthermore. the hallucinations were coherent. made sense. and in some children were congruent with their life experiences and circumstances. Hallucinations in schizophrenic children are usually associated with a host of other symptoms. are bizarre. and they often make no sense (Bender. 1970: Eggers. 1978: Portell. 1970). The hallucinations of most patients were reversed early in the course of treatment. A similar outcome in his patients was reported by Lukianowicz (1969) . The early reversal of the hallucinatory experiences. or else the favorable outcome. was probably due to two factors . First. it was the unconditional alliance and support offered to most children by therapists. Second. it was the alleviation of stress that was associated with counseling and with substantial changes in the life circumstances of some children. e.g.. placement in appropriate school program (cases 3. 8. and II). The evidence therefore suggests that the short-term prognosis regarding the hallucinatory experiences is generally good provided that the associated emotional disturbance and stress factors have been understood and dealt with effectively. Other underlying conditions (e.g.. attention deficit disorder. learning disability) will eventually continue their natural history course. The intervention was ineffective in one child (case I). At least two conditions stood out as being specific to him . First. he started to hallucinate at age 5 1h years and for 1112 years he received no professional help . By the time he was assessed and treated. therefore. this child was a chronic case. Secondly. this was an unusually reflective child for his age who would not become involved in play. Instead. he would converse as a much older child . It was not possible to determine whether his family psychiatric history and meningitis in infancy were important factors . A second child (case 7). with schizoid disorder. was showing some improvement but this appeared to be precarious. The hallucinatory experiences in this child were obviously associated with serious psychiatric pathology compatible in many respects with a borderline syndrome as described by Bemporad et al. (1982) . Whether hallucinations in children may be considered precursors of an imaginative person. such as an artist or a writer. as it has been postulated by Wilson and Barber (1983).
380
KOTSOPOULOS ET AL.
is difficult to tell. Only two of the patients (cases I and 7) appeared to have rich imaginary lives. They were, in fact, the two with poor outcomes. Regarding the psychodynamics of the hallucinatory experience, it may be speculated that all patients under conditions of heightened stress who were feeling either isolated or unsupported by sources of affective support, such as parents, experienced disassociation in the functions of the self. The disassociated part was projected to an alien source and became the hallucinatory experience. After treatment commenced the child felt supported and the stress eased. Consequently, the child started to deal with his or her problems without feeling overwhelmed or helpless; then, the hallucinations ceased. As the number of the subjects of the present study was small. firm conclusions may not be drawn about the issues this study attempted to address. The results of the study, however, may be useful in developing hypotheses on the psychopathology that underlines hallucinatory experiences in children. One hypothesis may be that intense emotional disturbance and high arousal level associated with chronic stress, and social ineptness, withdrawal, and disruption in the affective support the child normally receives from parental figures, are necessary but probably not sufficient factors for the emergence of the hallucinatory experience. What the additional necessary and sufficient factors are, perhaps in the form of some inner vulnerability, has yet to be determined.
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Egdell, H. G. & Kolvin, I. (1972), Childhood hallucinations. J. Child Psychol. Psychiat., 13:279-287. Eggers, C. (1978), Course and prognosis of childhood schizophrenia. 1. Aut. Childh. Schi:o., 8:21-36. Eisenberg, L. (1962), Hallucinations in children. In: Hallucinations, cd. L. J. West. New York: Grune & Stratton, pp. 198-207. Exner, J. E. Jr. & Weiner, I. B. (1982), The Rorschach: A Comprehensive System, Vo!' 3. Assessment of Children and Adolescents. New York: Wiley. . Fish, F. (1974), Fish's Clinical Psychopathology, ed. M. Hamilton. Bristol: John Wright & Sons. Garralda, M. E. (1982), Hallucinations in psychiatrically disordered children: preliminary communication. J. Royal Soc. Med., 75: 181184. Jaspers, K. (1963), General Psychopathology. trans. J. Hoenig & M. W. Hamilton. Chicago: University of Chicago Press. Keith, P. R. (1975), Night Terrors: a review of psychology, neurophysiology and therapy. This Journal, 14:477-489. Levin, M. (1932), Auditory hallucinations in non-psychotic children. Amer. J. Psychiat., 88:1119-1152. Lewis, M. (1982). Clinical Aspects (If Child Development. Philadelphia: Lea & Febiger. Lukianowicz, N. (1969), Hallucinations in non-psychotic children. Psvchiat. Clin., 2:321-337. Mavromatis, A. & Richardson, J. T. E. (1984), Hypnagogic imagery. In: International Review of Mental Imagery. Vol. I, ed. A. A. Sheikh. New York: Human Sciences Press, pp. 159-189. Portell, J. (1970), Hallucinations in pre-adolescent schizophrenic children. In: Origin and Mechanisms (if Hallucinations, cd. W. Keup. New York: Plenum, pp. 405-411. Rothstein, A. (1981), Hallucinatory phenomena in childhood: a critique of the literature. This Journal, 20:623-635. Savage, C. W. (1975), The continuity of perceptual and cognitive experiences. In: Hallucinations, cds. R. K Siegel & L. J. West. New York: Wiley, pp. 257-286. Simonds, J. F. (1975), Hallucinations in non-psychotic children and adolescents. 1. Youth Adolesc., 4: 171-182. West, L. J. (1975), A clinical and theoretical overview of hallucinatory phenomena. In: Hallucinations, eds. R. K. Siegel & L. J West. New York: Wiley, pp. 287-311. Wilking, V. N. & Paoli, C. (1966), The hallucinatory experience. This Journal,5:431-440. Wilson, S. C. & Barber, T. X. (1983), The fantasy-prone personality: implications for understanding imagery, hypnosis, and parapsychological phenomena. In: Imagery, Current Theory, Research and Application, ed. A. A. Sheikh. New York: Wiley pp. 340-387.